Prior Authorizations and Part D

Posted:May 11, 2015

Have you ever been prescribed a new medication from your doctor, went to the pharmacy to pick it up, only to be told it needed a Prior Authorization? There are many cases when the Pharmacist will tell you they will take care of it with your doctor but what does that mean to you?

A Prior Authorization means that the plan needs more information from your Doctor to make sure the drug is being used correctly for a medical condition covered by Medicare.

Certain prescriptions require that your Doctor send in a Prior Authorization letter with additional information about the condition being treated for approval under your Part D plan. These medications are usually denied as the drug is characterized as cosmetic, expensive, and/or non-medically necessary. Other reasons have been noted for high doses, age limiting medications, and Brand name drugs that are available in generic. 

  • When your prescription is denied as “Needs Prior Authorization” at the pharmacy or mail order, your doctor is required to submit additional information. Next, the insurance company reviews what the doctor submitted and determines an approval or denial on your medication.
  •  If the Prior Authorization is approved, the insurance company will cover the prescription and you will only be responsible for your plan co-pay.
  •  If the Prior Authorization is NOT approved, you have the option to have request your Doctor put in an Appeal, in which the insurance company will request more documentation from the doctor for a second review. There is a 60 day period from the initial denial to request an appeal.

For more information about Prior Authorizations please call a retiree advocate at 856-316-7226.